Disclosure: Wayne Katon, MD Lilly Wyeth Forest Pfizer

I I I I

I I

Company

Employment

Management

Independent Contractor

Consulting

Speaking & Teaching

Board, Panelor CommitteeMembership

Enhancing Treatment for Patients with Comorbid Depression, Diabetes

and Heart DiseaseWayne Katon, MD1

Mike VonKorff, ScD2

Elizabeth Lin, MD, MPH2

Paul Ciechanowski, MD, MPH1

Greg Simon, MD, MPH2

Evette Ludman, PhD2

Joan Russo, PhD1

Carolyn Rutter, PhD2

Bessie Young, MD, MPH1

1 University of Washington School of Medicine2 Center for Health Studies, Group Health Cooperative NIMH Grants MH 4-1739 and MH 01643 (Dr. Katon)

Mrs. K is a 45-year-old female computer programmer with a 5-year history of type 2 diabetes. She started the study in Sept. 2007 based on the following eligibility criteria: PHQ-9 of 20, HbA1c 9.6.

Patient has a history of childhood sexual abuse, has had recurrent depressive episodes and obesity with a BMI of 51 (>30 meets obesity criteria). Prior history of smoking and has sleep apnea Rxed with CPAP.

Adverse Bidirectional Interaction

Major Depression

• Smoking

• Sedentary lifestyle

• Obesity

• Lack of adherence to medical regimens

• Psychophysiologic

Insulin sensitivity Autonomic NS Inflammatory markers

• Medical illness at earlier age

• Poor symptom control

functional impairment

complications of medical illness

mortality

Katon et al. Biol Psychiatry 2003

Premature Mortality and Chronic Mental Illness

Schizophrenia: 20-25 years Bipolar: 10-15 years Major Depression: 5 to 10 years

Etiology of Premature Mortality

Suicide, accidents Medical morbidity

Medical Morbidity Chronic stress: effects on HPA axis,

autonomic nervous system, immune system

Health risk behaviors: smoking, sedentary lifestyle, diet/obesity, alcohol/drugs

Lack of self care: adherence to medication, diet, exercise, cessation of smoking

Psychiatric medications: obesity, metabolic syndrome, diabetes, CAD

Behavioral Risk Factors: Depression

Behavioral risk factors (smoking, obesity, sedentary lifestyle) account for approximately 40% of all deaths in the U.S.

Depression is linked to all 3 Wassertheil-Smoller (2004) have shown in

98,000 women that depression was associated with higher rates of smoking, lack of exercise, obesity, diabetes, high cholesterol levels and rates of hypertension compared to non-depressed populations

Meta-Analysis of the Effect of Depression on Patient Adherence

Compared to nondepressed patients, the odds are 3 times greater that depressed patients would be nonadherent with medical treatment recommendations

DiMatteo MR et al. Arch Intern Med 2000

02468

1012141618

None Minor Major

Depression Group

% S

mok

ing

% Smoking by Depression Level

Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type , HbA1c and clinic

N = 4,225p<0.001; Major > Nonep<0.01; Minor > None

Katon et al. Diabetes Care 2004

% BMI > 30 kg/m2 by Depression

01020304050607080

None Minor Major

Depression Group

BM

I >

30

kg/

m2 (%

)

N = 4,225p<0.001; Major > Nonep<0.01; Minor > None

Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type, HbA1c and clinic

Katon et al. Diabetes Care 2004

HbA1c > 8% by Depression Level

0

10

20

30

40

50

60

None Minor Major

Depression Group

Hb

A1c >

8%

(%

)

Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type and clinic

N = 4,225p<0.001; Major > Nonep<0.01; Minor > None

Katon et al. Diabetes Care 2004

18.8 19.321.6

24.527.2 27.9

0

10

20

30

40Non DepressedDepressed

Medication Adherence in Patients with Diabetes

Oral Hypoglycemic

Lipid LoweringMeds

ACEInhibitors

No

nad

her

ent

Day

s (%

)

Lin et al. Diabetes Care 2004

Pathways Epidemiology Study

Baseline

Mail Survey1 2 3 4

5-YearTelephone

Survey

Disease control (HbA1c, LDLs, blood pressure)

Pharmacy refills (adherence)ICD-9 diagnosisMacrovascular/microvascular complications (chart

review)Mortality (Washington State mortality data)

Depression: Association with Complications and Mortality

Minor Depression

Major Depression

Microvascular Complications

1.05 (0.83, 1.33) 1.33 (1.08, 1.65)

Macrovascular Complications

1.32 (0.99, 1.75) 1.38 (1.08, 1.78)

Mortality

(All cause)1.23 (0.94, 1.61) 1.53 (1.19, 196)

Foot Ulcers 1.50 (0.82, 2.60) 2.30 (1.50, 3.70)

Pathways Randomized Controlled Trial Participants randomly assigned to

Pathways nurse collaborative care intervention (N = 165) vs. usual care (N = 164)

Usual Care Primary care or referral to specialty MH care

as available Pathways Care

Collaborative/stepped care disease management program for depression in primary care

Katon et al. Arch Gen Psych 2004

Treatment Protocol

Behavioral activation/pleasant events scheduling Antidepressant medication

Usually an SSRI or other newer antidepressantOR

Problem Solving Treatment in Primary Care (PST-PC)

6-8 individual sessions followed by monthly group

maintenance sessions

Maintenance and Relapse Prevention Plan For patients in remission

Katon et al. Arch Gen Psych 2004

Intervention vs Control Differences on Mean SCL Depression Scores (Range 0 – 4)

0.5

1

1.5

2

I UC

Baseline 3 mos 6 mos 12 mos

Mea

n S

CL

-20

Dep

ress

ion

Sco

re

Katon et al. Arch Gen Psych 2004

6

6.5

7

7.5

8

Intervention vs Control Differences on Mean HbA1c

I UC

Baseline 6 mos 12 mos

Mea

n H

bA

1C %

Katon et al. Arch Gen Psych 2004

Intervention vs. Usual Care Differences in Health Risk Behaviors No significant I vs. UC differences in

exercise, diet, smoking or checking blood glucose

Intervention patients had a significantly lower mean BMI level compared to UC at 12 months

Lin et al. Arch Fam Med 2006

Depression: Diabetes Lower Total Health Care Costs Over 2 Years

Usu

al C

are

Inte

rven

tio

n

Sav

ing

s

Usu

al C

are

Inte

rven

tio

n

Sav

ing

s$0

$5,000

$10,000

$15,000

$20,000

$25,000

Pathways IMPACT

$22,258

$21,148 $18,932$18,035

$1,110$897

Treating depression and other mental Illness is a necessary

first step, but not sufficient alone to improve health risk

behaviors and chronic medical disease control

Health Services Models

TeamCare Approaches have been shown to improve quality of care and outcomes of patients with depression, diabetes, asthma and CHF

The most complex and medical costly patients often have multiple comorbidities including at least one mental health diagnosis

Medicare Patients Depression, diabetes and heart disease are

among the most common illnesses in aging populations but fewer than 4% of Medicare beneficiaries with any of these three illnesses have no other chronic medical conditions

80% of those with CHF, 71% with depression and 56% with diabetes have 4 or more chronic conditions

Partnership for Solutions 2001

Diabetes: Achieve Recommended Risk Factor Targets

Less than 10% of diabetes patients attain

recommended goals for: HbA1c < 7.0%, Systolic

BP < 130 and LDL < 100mg Poor Adherence found in 20% of patients No evidence of poor adherence but lack of Rx

intensification found in 30% of hyperglycemia patients, 47% of hyperlipidemia patients and 36% of hypertensive patients

Schmittdiel J et al. JGIM 23:588-94, 2008

Challenge: Development of Health Services Models for

“Natural” Clusters of Illness

Examples: Diabetes, CAD, depression Depression, chronic pain, substance

abuse

Definition: Illnesses with high prevalence, high comorbidity and bidirectional adverse interactions

New NIMH-Funded Study: TeamCare Inclusion Criteria

Evidence via automated date (ICD-9) of having diabetes and/or coronary artery disease (CAD)

Evidence of poor disease control (HbA1c > 8.5, blood pressure >140/90, LDL >130)

PHQ-9 > 10

10,000 Group Health patients with diabetes and/or CAD & poor disease control

Screen 1: PHQ-2 (response rate 82.6%)

14.8% positive (>3 on PHQ-2)

Screen 2: 1066 eligible for SQ-2 with PHQ-9

268 with PHQ-9 >10 completed baseline

>200 randomized

TeamCare Intervention Goals

Improve depression care: behavioral activation and antidepressants

Improve medical disease control: HbA1c, HTN, LDL

Improve self-care (diet, exercise, cessation of smoking, glucose checks)

TeamCare Interventionists

3 diabetes nurse educators Caseload supervision

Depression: 2 psychiatrists Diabetes and CAD: nephrologist, family

doctor E-Mail to diabetologist for complex

cases

Nurse Training

Motivational interviewing Problem solving Behavioral activation Antidepressants TREAT-to-TARGET: blood glucose,

HTN, LDLS

Initially, the case manager increased the patient’s Celexa from 20 to 60 mg and also began working with the patient on monitoring blood sugars more frequently and increasing NPH insulin. Trazadone was also added to help with sleep. Her HbA1c decreased by December to 8.4%. PHQ score initially decreased from 20 to 12 on Celexa 60 mg. and Trazodone 50 mg and Wellbutrin was added at 100 SR with gradually increasing dosages. By mid-November, her PHQ had decreased to a 5 on Celexa 40 mg, Wellbutrin SR 200 mg BID, Trazodone 50 mg.

TeamCare Summary Report

Initial Clinic Enroll DatePHQ

BL Now

BP

BL Now

HbA1c

BL Now

LDL

BL Now

NSH 5/19/08 19 19141/69

127/77

7.3 6.8 168 138

NSH 1/9/08 15 2118/80

130/80

9.2 8.3 138 124

EVM 11/12/07 14 9160/98

150/85

6.4 6.8 108 67

EVM 10/30/07 13 2209/119

126/76

7.3 7.7 119 103

LYN 8/23/07 14 3149/71

111/58

8.1 7.7 85 82

Improving Adherence

Patient self-care materials: book and video on depression, patient manual (Tools for Managing Your Chronic Disease)

Nurse support/education/motivational interviewing

Medisets Simplifying medication regimen $4 generics to avoid $10 co-pays

Self-Care Enhancements

Glucometers: Group Health provides Home blood pressure monitors Pedometers to increase exercise Medisets to improve adherence

Phases of Treatment

Intervene on depression initially Behavioral activation Antidepressant medication

Medical Disease Control Is patient adhering to medication regimen? If adhering and in poor control, is patient

on optimal dosage? If maximum dosage has been reached

should a new medication be tried instead or augmentation of initial medication?

Team recommendations of medication changes are reviewed with primary care physician for approval

Behavioral Goals

Behavioral activation/exercise Dietary changes Checking blood glucose/altering

insulin Cessation of smoking

The nurse worked with the patient in January/February 2008 on increasing exercise and weight reduction. Patient also began to gather information about gastric bypass surgery. She began to watch food proportion sizes, worked out on a treadmill and joined a pregastric bypass group. Her PHQ-9 in June was a 7, HbA1c 7.4%, blood pressure 113/82 (had decreased from 132/80) and LDL was 77 (had decreased from 101).

.

Conclusions Patients with common psychiatric illnesses

have significantly shorter life spans due to premature development of medical illnesses.

Economies of scale: New health services interventions are needed for patients with multiple comorbidities (one of which is a psychiatric disorder).

Integration of evidence-based mental health interventions into primary care and preventative medical interventions into community mental health care are needed to enhance outcomes of patients with comorbidities.